–Phases of Illness |
–Psychological Complications of Cancer |
"Not life, but good life, is to be chiefly valued." —Socrates A landmark epidemiologic study by Derogatis and colleagues1 revealed that 47% of a broad sample of cancer patients qualified for at least one psychiatric diagnosis usingdiagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition. If 2003 cancer incidence data2 are used, this prevalence rate would mean that roughly 627,000 of the patients diagnosed with cancer each year suffer with clinically significant comorbid psychological disorders or symptoms. If those who bear the burden of subclinical suffering and distress are included, an evengreater overall number of cancer patients might benefit from intervention. Psycho-oncology is a clinical subspecialty focusing on the psychological, behavioral, and social aspects of cancer. Dimensions of psycho-oncology include the psychological consequences that patients experience at various stages of disease and the possible effect that psychological, behavioral, and social responses have onmorbidity and mortality.3 Entire textbooks and chapters on this subject are available to the interested reader.4–6 Psychiatrists and psychologists working in psycho-oncology assist patients in adapting to life after a cancer diagnosis, coping with medical interventions, adjusting to survivorship, and facing disease progression or terminal illness. This chapter on psychological issues in oncologyfocuses on the phases of cancer-related illness and the psychological complications associated with each illness phase. The presentation, diagnosis, and practical first-line management of psychological and psychiatric complications of cancer and its treatment are also addressed. Phases of Illness Initial DiagnosisApproximately 90% of the observed psychiatric disorders in the Derogatis et al.1 studywere reactions to the cancer diagnosis or treatment. Given the threat to life and well-being that cancer represents, most people experience stress in response to the diagnosis. Stress refers to any event in which the internal or external demands are perceived as taxing or exceeding the adaptive resources of an individual.7 Every potentially stressful event is filtered through this cognitiveappraisal process, and, thus, no two people experience any event in the same way. Responses to the cancer diagnosis vary widely based on disease-related factors, such as the type, stage, and location of cancer, the treatment selected, and treatment outcomes. Furthermore, the individual's age, sex, and education moderate levels of distress. Finally, reactions to the cancer diagnosis are mediated byprevious experience with cancer patients, social support, hope, and use of coping strategies. Coping entails efforts to master the condition that is stressful, which often requires a novel response from the individual. Coping responses can be divided into two main categories: problem-focused coping and emotion-focused coping.7 Problem-focused coping includes efforts to improve the situation by takingaction to change things. Problem-focused coping is particularly useful in situations in which the person's efforts can actually modify the stressor. Pursuing all options to eliminate disease is an example of problem-focused coping. On the other hand, emotion-focused coping involves strategies that are used to relieve the emotional impact of stress. Examples include talking about fears, joking,distancing, relaxation, and distraction. These actions are designed not to change the situation but to make the person feel better about the event. Emotion-focused coping strategies tend to be more effective than problem-focused coping strategies when the stressor itself is outside the individual's control, as is the case with many illness-related stressors. The most difficult time for patients is...